1. Presbyopic Treatments in Refractive Surgery:
Building the Bridge Between LASIK and Implants
Shareef Mahdavi • SM2 Consulting • Pleasanton, CA
Surgeon and consumer interest in refractive surgery contin- presbyopic population is largely invisible to the ophthalmic
ues to grow, with LASIK firmly established as a “category practice. This is especially true of the plano presbyope, who has
leader” and IOL implants evolving into a refractive segment up until now never entered the eye care delivery system due to
with lenses that can restore vision for near, intermediate and lack of need (and a lifetime of “perfect vision”). As with the
distance vision. These two “book end” solutions address development of LASIK, it will likely take several years of con-
both ends of the refractive spectrum, with the laser able to sumer-directed messaging from doctors, manufacturers and the
address ammetropia earlier in adulthood and implants resolv- media to help create awareness that solutions for presbyopia are
ing cataracts later in life. In the middle of this spectrum lies increasingly available.
presbyopia. This paper attempts to help refractive surgeons The above-mentioned dynamic helps explain the frustration
understand the significance of this opportunity and their role experienced by refractive surgeons who offer CK (conductive
in helping build a bridge between the two ends of the refrac- keratoplasty); they find it difficult to reach and attract this
tive spectrum. Special attention will be paid to the post- “invisible” patient segment of plano presbyopes. With greater
LASIK population, which serves as an ideal target to begin awareness, future approved technologies (eg, corneal inlays) and
building a presbyopic treatment “practice within a practice.” a change in the message about presbyopia heard by the public,
that frustration should lessen over time. CK providers are, how-
Size of Market ever, not waiting and are tapping into a population that is visi-
Sometime early in 2006, 5 million patients (10 million eyes) ble and easily identifiable to the surgeon: the post-op LASIK
will have undergone LASIK (or PRK) since the excimer laser patient who is now presbyopic.
was first approved a decade earlier. According to data published
by Market Scope Newsletter (St. Louis, MO), the current rate of Post-LASIK Presbyopia
LASIK adoption is 1.4 million eyes per year in the US with The post-LASIK patient is a strong fit for presbyopic refrac-
patients averaging 40 years of age. Similarly available data on tive solutions for two reasons. First, the fact that they have
IOL implants show a run rate of 2.7 million eyes per year and already undergone LASIK shows a favorable pre-disposition to
rising with an average age that is likely to decline below 65 refractive surgery; LASIK patients have already made it through
years (medicare eligibility) due to an increase in the mix of IOLs the “fear hurdle.” Second, they are readily identifiable to the
being used in private-pay cataracts that present earlier than this surgeon as part of the practice patient database; this makes
as well as refractive lens exchange (RLE) procedures. them much easier (and less expensive) to reach than the overall
These incidences of treatment still represent single-digit per- presbyopic population.
centage penetration of the overall US adult population, which is
segmented in Figure 1 to show the relative size of three key age
ranges. Both LASIK and implants are available to a significant Figure 1: US Population: 2006 (millions)
percentage of people in these age ranges. What makes presby-
Source: US Census Data
opia distinct is that current and emerging solutions apply to just
100
about 100% of the adult population as it gets older. This 90
unavoidable reality that affects an aging body is what drives 80 93
70 million
manufacturers to significantly invest in solutions to help the
60
presbyopic population move beyond reading glasses. 50 62
40 million
Where are the Presbyopes? 30 37
20 million
For decades, presbyopes have been turned away by ophthal- 10
mologists, having been told that no solutions exist beyond read- 0
Age 25-39 Age 40-64 Age 65+
ing glasses available at the local drugstore. As a result, the

2. Defining the Pool of Post-LASIK Presbyopes opes over the next decade, all emerging from LASIK patients
Retrospective analysis of Market Scope data was done to treated in the past decade. Similar estimates are shown for sur-
quantify the the pool of LASIK patients that are now or soon geons whose procedure volumes have averaged 600, 900 and
will be presbyopic. A year-by-year count of patients treated at 1,500 eyes per year over the past decade. Using $1,600 per eye
each age during the previous 10 years was done to determine the as an average fee for CK, the total monetary value of this pool
number of patients who are now 40 but were younger at the time of presbyopes already within the reach of the refractive surgeon
of LASIK, as well as patients who were between 40 and 45 years ranges from $2.4 million to $9.2 million over the next decade,
of age at the time of surgery. We intentionally exclude patients based on the data in Column D.
that were above 45 years of age, as the incidence of ocular path-
ology (eg, yellowing of the lens) increases significantly with age Building the Bridge
and would likely preclude being indicated for a procedure whose For LASIK surgeons who will be doing refractive IOLs, CK
sole purpose is to treat presybopia. Screening for these factors in represents an opportunity to create a bridge for LASIK patients
the LASIK population yields a total of 1.6 million post-LASIK who will eventually require an implant. This requires a shift in
patients that we define as early or “emerging” presbyopes. how a refractive surgeon views his business model. Traditionally,
At one-third of all eyes treated via LASIK or PRK to date, refractive as well as cataract surgeons have viewed the patient
this 1.6 million population is large in size and worthy of atten- encounter as a one-time event: Catch them, treat them, and send
tion. As described above, these post-LASIK patients are a them on their way. The bridge that is built during the emerging
highly-refined target audience for treatments such as CK. presbyopic years puts the surgeon in the position of maintaining
a relationship with the patient that spans several decades. As put
Figure 2: Accumulation of Emerging Presbyopic forth by Durrie, the implications to patient flow and manage-
Patients in the Refractive Surgery Practice ment in this new model require the refractive surgeon to behave
more like a glaucoma specialist: See the patient every year and
A B C D
educate him or her on their eye health and refractive options as
Surgeons who have Have And will be adding Generating a total their visual needs change. Far from being part of a single
been averaging accumulated this many more pool of emerging
this many LASIK this number emerging presbyopes in the encounter, the patient stays as part of the active patient base and
procedures (eyes) of emerging presbyopes each practice that
per year... presbyopes year over the next equals... is contributing to practice revenue throughout their adult life.
over the past decade...
decade... (range per year)
Conclusion
400 (35 eyes per month) 500 115 to 200 1,500 patients
For the ametrope who chose laser vision correction to
600 (50 eyes per month) 740 170 to 300 2,300 patients
improve distance vision, presbyopia becomes the proverbial
900 (75 eyes per month) 1,470 250 to 450 3,500 patients “midpoint” in vision between “being younger” and “getting
older.” Advances of technology have made it possible for sur-
1,500 (125 eyes per month) 1,840 425 to 750 5,800 patients
geons to stop turning away presbyopes and start educating them
on new opportunities to improve their vision. Surgeons, espe-
Post-LASIK Patients: Forward Momentum cially those who are going to provide refractive IOLs to their
Further analysis was done to estimate the number of post- patients, should view presbyopia and its affect on near vision as
LASIK patients that exist in the typical refractive practice as an opportunity to extend the relationship they already have with
well as how that segment will expand in the practice over the their previously-treated LASIK patients. Doing so builds a bridge
next decade (see Figure 2). Column A shows different levels of in this relationship which shifts the doctor-patient relationship
annual LASIK volume achieved over the past decade. A surgeon from serving needs during a single encounter to fulfilling vision
who has been averaging 400 LASIK procedures each year – 30 needs as they change over several decades.
to 35 eyes per month – should have approximately 500 patients
References:
already in his practice who are emerging presbyopes (Column US Government Census Website www.census.gov
B). Based on the LASIK already performed over the past 10 Harmon, D. Market Scope Newsletter (St. Louis, MO). Monthly, from 1998 through 2005.
Mahdavi, S. CK: Worth a Second Look?, Cataract and Refractive Surgery Today,
years, that surgeon can expect another 115 to 200 patients each September 2005, pp. 97-101.
Durrie, D. A New Economic Model for Managing Refractive Patients.
year (Column C) to be added to his pool of emerging presby- Presentation at Refractec Breakfast Symposium, October 16, 2005, Chicago, IL
opes. This forward momentum equates to 1,500 more presby- © Copyright 2006, SM2 Consulting. All rights reserved.